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Health Care Decision Making in Maryland. Paul Ballard, Esq., Assistant Attorney General Counsel for Health Decisions Policy and the Office of Health Care Quality Howard Sollins, Esq., Ober Kaler. Health Care Decisions Act. - PowerPoint PPT Presentation
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Health Care Decision Making in MarylandPaul Ballard, Esq., Assistant Attorney GeneralPaul Ballard, Esq., Assistant Attorney GeneralCounsel for Health Decisions Policy and the Counsel for Health Decisions Policy and the Office of Health Care QualityOffice of Health Care Quality
Howard Sollins, Esq., Ober KalerHoward Sollins, Esq., Ober Kaler
22
Health Care Decisions Act
The Health Care Decisions Act applies in all health care settings and in the community throughout Maryland
It became effective on October 1, 1993
Four Considerations
1. Who is the Decision Maker?
2. What are Qualifying Conditions?
3. What are Advance Directives?
4. What is Medical Ineffectiveness?
33
Who is the Decision Maker?
55
Presumption of Capacity
A patient is presumed to have capacity until two physicians certify that the individual lacks the capacity to make health care decisions or a court has appointed a guardian of the person to make health care decisions
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Certification of Incapacity If the individual lacks capacity, the
attending physician and a second physician must certify in writing that a patient lacks the capacity to make health care decisions– One of the physicians must have examined
the patient within two hours before making the certification
Only one physician’s certification is needed if the patient is unconscious or unable to communicate by any means
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Who Makes Decisions if the Patient Lacks Capacity
1. A designated health care agent
2. If no agent is designated or the agent is not available or is unwilling to act, a surrogate decision maker is used
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Determining the AppropriateSurrogate Decision MakerIf there is no health care agent, Maryland lawspecifies the type and order of the surrogatedecision maker(s) as follows:1. Guardian of the person2. Spouse or domestic partner3. Adult child4. Parent5. Adult brother or sister6. Friend or other relative
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Domestic Partners
Not related to the individual Not married Gender irrelevant “In a relationship of mutual inter-
dependence in which each contributes to the maintenance and support of the other”
1010
Authority of Surrogates All surrogates in a category have the
same authority All surrogates of equal authority must
agree on a decision regarding life-sustaining interventions
A physician may not withhold or withdraw life-sustaining procedures if there is disagreement among persons in the same class
1111
Resolving Disputes AmongEqually Ranked Surrogates Hospitals and nursing homes are
required to have a patient care advisory committee
Refer the issue to the patient care advisory committee
Attending physician has immunity for following the recommendations of the patient care advisory committee
1212
Patient Care Advisory Committee Patients, family members, guardians,
or caregivers may request advice from the committee
Committee must notify patients, family members, guardians, and health care agents of the right to discuss an issue
Committee’s advice is confidential and members not liable for good faith advice
1313
Documenting the Process
The process that has been used in determining the correct surrogate decision maker should be documented in the medical record
When the patient is transferred to another care setting, contact information for the surrogate decision maker should be sent to the receiving facility or program
What are Qualifying Conditions?
1515
Withdrawing Life-Sustaining Treatments If no health care agent was appointed,
then life-sustaining treatments may only be withdrawn when:
1. Certification of incapacity by attending physician and second physician
2. Certification of condition by attending physician and second physician which could include: Terminal condition End-stage condition Persistent vegetative state
1616
Withdrawing Life-Sustaining Treatments Or, two physicians certify a
treatment as medically ineffective for this patient
1717
Terminal Condition
A terminal condition is incurable There is no recovery despite life-
sustaining procedures Death is imminent, as defined by a
physician
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End-stage Condition An advanced, progressive and
irreversible condition caused by injury, disease, or illness
Severe and permanent deterioration indicated by incompetency and complete physical dependency
Treatment of the irreversible condition would be medically ineffective
1919
Persistent Vegetative State The individual has no awareness of self
or surroundings Only reflex activity and low level
conditioned responses Wait “medically appropriate period of
time” for diagnosis One of two physicians who certify a
persistent vegetative state must be a neurologist, neurosurgeon, or other physician who is an expert in cognitive functioning
What are Advance Directives?
2121
Advance Directive An advance directive is a written or
electronic document or oral directive that:
1. Appoints a health care agent to make health care decisions - and/or –
2. States the patient’s wishes about medical treatments when the patient no longer has capacity to make decisions (living will)
2222
Living Will
A living will contains a patient’s wishes about future health care treatments.
It is written “if, then”:– “If I lose capacity and I’m in
(specified conditions),– Then use or do not use a specific
medical intervention
2323
Authority of a Health Care Agent The advance directive determines
when the health care agent has authority– “When I can no longer decide for myself”:
The individual may decide whether one or two physicians must determine incapacity
– “Right away”: When the document is signed, the agent has authority
2424
Basis of Agent’s Decisions The health care agent is to make
decisions based on the “wishes of the patient”
If the patient’s wishes are “unknown or unclear,” then decisions are to be based on the “patient’s best interest”
2525
An Exception to Following a Living Will In some instances, a living will may
allow the health care agent to act in the patient’s best interest, regardless of what wishes are stated in the living will
Most living wills are not written this way
2626
Revoking an Advance Directive A competent individual may revoke
an advance directive at any time by:1. Completing a new written or
electronic advance directive2. Giving an oral statement to a
health care practitioner3. Destroying all copies of the
advance directive
Can an ADM make or revoke an advance directive? An authorized decision maker cannot
make or revoke a patient’s advance directive
2727
“Mom didn’t understand what she signed”
See the link below:
http://www.dhmh.state.md.us/ohcq/download/alerts/alert-v1-n1-sum2002.pdf
2828
What is Medical Ineffectiveness?
3030
Medical Ineffectiveness
A medically ineffective treatment is a medical procedure that will not prevent or reduce the deterioration of the patient’s health or prevent impending death
Physicians need not offer medically ineffective treatments
3131
Advising Patients of Medical Ineffectiveness
If two physicians determine an intervention is medically ineffective, the patient or ADM must be informed of the decision
The physician must make a reasonable effort to transfer the patient to another physician if the patient or ADM requests it
Pending transfer, the physician must provide the requested treatment if failure to do so would likely result in the patient's death
3232
Medical Ineffectiveness in the Emergency Room In an Emergency
Room, if only one physician is available, a second physician certification of medical ineffectiveness is not required
3333
For More Information
Marylandmolst.org
Paul Ballard, Assistant Attorney General410-767-6918